The impact of frailty on clinical outcomes in colorectal cancer surgery: a systematic literature review

Abstract

Background The majority of colorectal cancer is diagnosed in people aged >65 years, yet the elderly are less likely to undergo curative surgery. Chronological age is poorly correlated with post‐operative outcomes and is not an acceptable measure of risk. Conversely, frailty is a strong predictor of poor post‐operative outcomes and presents an opportunity for optimisation. This systematic review aims to assess the evidence between frailty and outcomes in patients of all ages undergoing colorectal cancer resections and to compare the predictive value of frailty status to that of age alone. Methods The review was registered on Prospero, CRD42019150542. PubMed was searched for articles reporting outcomes for frail patients undergoing elective or emergency colorectal cancer resection up until August 2019. All studies reporting outcomes in frail patients were deemed eligible for inclusion and assessed according to the PRISMA guidelines. Results Of the 143 identified studies, 17 were eligible for inclusion. Study type, frailty assessments and outcomes measured were highly variable. ‘Frailty’ was associated with significantly higher rates of post‐operative complications (7/7 studies), post‐operative mortality (5/7 studies), readmission (3/4 studies) and length of stay (3/3 studies). Seven of 11 studies reported no association between age and adverse outcomes. Conclusion Frailty is a predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. Standardisation of frailty assessment and outcome measure is needed. Accurate risk stratification of patients will allow us to make informed treatment decisions, identify patients who may benefit from preoperative intervention and tailor post‐operative care.

Short-term outcomes of colorectal cancer surgery in older patients: a novel nomogram predicting postoperative morbi-mortality

“…Moreover, age did not present any association with surgical site infection, anastomotic leak, or with reoperation rate. These findings are consistent with those obtained from other large series, where age was not predictive of in-hospital complications or mortality, suggesting that other conditions may impact more significantly in surgical outcomes [ 8 , 12 , 14 , 19 , 20 , 25 ]. Therefore, it would be more appropriate to consider a frailty index rather than age in preoperative decision-making.…”

“…Several factors have been identified that could increase the risk of postoperative adverse events in older patients: comorbidities, male sex, tumor location, operation time, open surgery, and emergent surgery. Interestingly, age has not appeared as a factor increasing postoperative complications or mortality rate [12,14,[17][18][19][20][21]. Some authors have reported comorbidities as the strongest predictors of postoperative complications in aged patients [8].…”

Short-term outcomes of colorectal cancer surgery in older patients. A novel nomogram predicting postoperative morbi-mortality.

“…Moreover, age did not present any association with surgical site infection, anastomotic leak or with reoperation rate. These ndings are consistent with those obtained from other large series, where age was not predictive of in-hospital complications or mortality, suggesting that other conditions may impact more signi cantly in surgical outcomes [8,12,14,19,20,23].…”

“…Several factors have been identi ed that could increase the risk of postoperative adverse events in older patients: comorbidities, male sex, tumor location, operation time, open surgery and emergent surgery. Interestingly, age has not appeared as a factor increasing postoperative complications or mortality rate [12,14,[17][18][19][20][21]. Some authors have reported comorbidities as the strongest predictors of postoperative complications in aged patients [8].…”

Predictive value of selected geriatric parameters for postoperative outcomes in older patients with rectal cancer – A multicenter cohort study

“…However, older patients are also a heterogeneous group with regard to comorbidities, physical capabilities and the presence of geriatric impairments such as decreased mobility, malnutrition, polypharmacy and cognitive problems. Several studies have found an association between these geriatric impairments and adverse postoperative outcomes in older patients with CRC [4][5][6][7]. Adequate risk stratification in older patients is required to support informed decision-making and to adjust perioperative strategies such as the implementation of prehabilitation (preoperative physical optimization) programs.…”